OPIOID SAFE- PRESCRIBING TRAINING IMMERSION (OSTI)

Transcription

1 OPIOID SAFE- PRESCRIBING TRAINING IMMERSION (OSTI) Case 105- Prep Materials University of Massachusetts Medical School Opioid Conscious Curriculum

2 Learner Prep Objectives The purpose of this prep material is to prepare you for the Opioid Safe-Prescribing Training Immersion (OSTI) Curriculum The following slides provide an introduction to some of the key tools that you should be familiar with before participating in the OSTI. Note that additional information and resources are in the notes section of these slides and on the website. By the end of this prep, you should be familiar with the following tools and concepts: Referring treatment resources including early discussion of medication assisted therapy (MAT) Administering and using readiness to change/confidence in change tool Recognition and early management of a patient who has overdosed Discussing Naloxone use Using the Screening, Brief Intervention and Referral for Treatment (SBIRT) tool Reading an EMS run sheet

3 Case 5- Learner Tasks 1. Take a substance use history 2. Talk to the patient about her substance use treatment history, what has worked well previously, and options for future treatment 3. Utilize SBIRT to develop a plan with the patient, including assessment of readiness and confidence in change 4. Ensure that the patient and partner can identify signs of opioid overdose 5. Demonstrate use of a naloxone atomizer (intranasal naloxone) and explain when and how to use it to patient and partner 6. Counsel patient regarding the chronic nature of substance use disorder as a disease 7. Evaluate history and risk of psychiatric comorbidity and opioid misuse

4 Recognition of Opioid Overdose Classic triad: Coma (depressed mental status) Pinpoint pupils Respiratory depression (<12 breaths/min in adults) All three may not be present

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6 Management of Opioid Overdose In medical setting: Restoration of oxygenation and ventilation are the first priorities Ventilation with BVM, supplemental oxygen administration Reversal using naloxone with escalating doses (dose titrated to restoration of respiration; excessive dosing may precipitate withdrawal) Naloxone dosing per table on following page

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8 Naloxone and opiate overdose Death generally occurs within 1-3 hours of overdose (Kin, 2009) Bystander naloxone use is associated with increased odds of recovery (Giglio, 2015) Discuss Naloxone with all patients who have an opiate use disorder Explain signs and symptoms of overdose Share handouts and review naloxone use Share website with videos regarding OD recognition and naloxone use by patients and bystanders

9 How to administer nasal naloxone From Prescribe to Prevent Three minute high-yield video -- Watch it here

10 Patient Handout OD & Naloxone

11 Screening, Brief Intervention, Referral to Treatment (SBIRT) Consists of Screening: assess the level of use, reasons for use, and other important factors (there are many specific tools and additional SBIRT information on the SAMHSA website) Brief intervention: engage the patient in conversation, consider using ruler to assess interest/willingness to change Referral to Treatment: based on availability and the patient s specific needs, interest, insurance. Watch this 7 minute video on using SBIRT for drug use Consider using an SBIRT app

12 Readiness/Confidence to Change Provides a framework for allowing the patient to address the motivation to change through importance, readiness, and confidence Asks patients to use a 10-point ruler (mostly validated in tobacco and Alcohol behavioral change) Miller 1991, Rollnick 1997, Boudreaux 2012, Zimmerman 2000 The patient is asked to score each of these items for the habit being addressed (e.g., heroin use) Providers then ask questions about their scoring Why not lower? can provide insight into their motivation Why not higher? can identify perceived obstacles An example ruler follows

13 Readiness/Confidence to Change

14 Substance Use Disorder Treatment

15 Substance Use Disorder Treatment is a continuum A given patient may need some or all of these levels of care at some point in their addiction; however, not all do

16 Substance Use Disorder Treatment Spectrum There are several options for SUD treatment. Patients may be amenable or eligible for more than one. Examples: Individual and group counseling Inpatient and residential treatment Intensive outpatient treatment Partial hospital prog. Case/care mgmt. Medication Peer supports 12-Step fellowship Recovery support svcs

17 Vocabulary for the SUD Inpatient Treatment Inpatient Detoxification Program ( Detox ): 4-6 days of inpatient medical monitoring of withdrawal symptoms. Focus on medical management of symptoms, some counseling services included. Clinical Stabilization Services (CSS): Intensive, short-term (up to 30 days) inpatient residential program. Focus on skills for early recovery. Transitional Support Service (TSS): Inpatient treatment (counseling, skills building) stepdown in transition to next step in care (often longer-term residential). Usually < 28 days. Short-Term Residential Treatment: 24 hours a day care, generally in non-hospital settings, often in therapeutic community model with varied lengths of stay of between 30 days-6months Long Term Residential Treatment: Residential treatment between 6 and 12 months Alcohol and Drug-Free Housing AKA Sober Home : Typically unstructured community of individuals in recovery from addiction, often requires drug monitoring is not state-regulated or licensed; Quality and intensity of housing varies; Many private companies, Half-way House: May refer to a Sober Home with more intensive treatment engagement requirements for individuals between residential treatment and independent sober living. Three-quarter House: May refer to Sober Home with fewer requirements than a half-way house, but more than minimum sober home requirements

18 Vocabulary for SUD Outpatient Treatment Partial Hospitalization Program: Intensive outpatient treatment usually 5 days/week all day group counseling and skills workshops Intensive Outpatient Program (IOP): Usually half-day 3-4 days/week group counseling and skills workshops Group counseling: Often once or twice weekly for 1-2 hours. Type of group is determined by the therapist and can include support groups, skills development and psychoeducational Individual counseling: One-on-one counseling sessions with behavioral health specialist Alcoholics Anonymous/Narcotic Anonymous: 12-step model (See below) Sponsor: An individual in recovery addict who is willing to share their knowledge with those who are less experienced in the program Resource for information about recovery Someone who is available to listen, guide Role model

19 Medication Assisted Treatment (MAT) To date, there is strong evidence to support the use of MAT (usually methadone, buprenorphine or naltrexone) in opioid addiction. Decreases withdrawal in the early phases of recovery Decreases cravings Decreases risky activities associated with obtaining medications or drugs Increases patient retention

20 Narcotics Anonymous Mutual aid groups like AA and NA have frequent meetings, and require no financial resources or insurance to participate 12-step programs Focus tends to be on drug-free living, sometimes to the exclusion of MAT Your patient may have a sponsor through AA or NA, that serves as additional support

21 Key Concepts Opioid use disorder (OUD) is a chronic illness and should be treated as such. The opiate epidemic has impacted communities of color for years. The current national focus suggests bias not only in prescribing, but in the response of the healthcare system, policy-makers and media. Safe prescribing does NOT mean NO prescribing -- even for patients in recovery. The prescription monitoring program (PMP or MassPAT) provides accurate, up to date prescribing information Co-prescribing naloxone should be considered for any patients on chronic opiates. Best practices include risk assessment (including diversion), informed consent, monitoring, safe storage and disposal counseling.